Inanimate Model for Laparoscopic Repair of Diaphragmatic Hernia

Benjamin R Veenstra, MD, John C Kubasiak, MD, Aleksandra Wojtowicz, Minh B Luu, MD, Jose Velasco, MD. Rush University Medical Center

Objective: The training of surgical residents to technical proficiency is at the core of surgical residency programs. However, new work regulations have made it increasingly challenging to train residents in a five year period, thus requiring novel educational paradigms. In fact, most residents seek additional training through fellowship programs, suggesting a void in the current model. Within this void, there is a need to practice and develop the skills necessary for complex laparoscopic, albeit institutionally low volume cases, as simple observation does not suffice.  The literature suggests that for advanced laparoscopic procedures, 50 cases are needed to reach a level of “expert.”  While most residents are not expected to graduate as an “expert,” volume and repetition are essential, with the foundation established in residency.  To answer the question of how to fill this void, many institutions are looking towards surgical simulation, particularly  the use of laparoscopic trainers.  However, most laparoscopic trainers are expensive and their value has not been fully established.  We propose that artificial physical models may fill this need.  

Description and Method:  We identified laparoscopic diaphragmatic hernia repair with Nissen fundoplication as an advanced laparoscopic, yet relatively low volume case at our institution.  We polled our graduating chief residents and found the average case load for this procedure was 5, well shy of 50.   We created an artificial physical model to address this deficiency by using an airway “dummy” head and torso (akin to those used for intubation practice) as the base. The diaphragm, crura with a hernia defect, hernia sac, esophagus, major vessels and stomach were built using mesh and plastinization and affixed to the base.  This model was validated at our Simulation Center after critique and adjustment by five advanced, laparoscopic upper GI surgeons in a fully functioning laparoscopic operating suite with videotaping capabilities.    

Completed Model - Exterior 

Laparoscopic Set Up 

Completed Model - Interior

Preliminary Results: Task deconstruction, specific learning objectives, and metrics were defined.  The model and set up provided an opportunity to complete the repair efficiently and safely while following accepted guidelines.  Users felt the model facilitated learning and practice of the technical components needed to complete a complex advanced laparoscopic case.  

Conclusions/Future Directions:  We feel a tactile model of advanced, yet low volume laparoscopic cases affords residents a more realistic opportunity to gain operative exposure, technique and skill.  Additionally, it is our belief that the skill acquired during the tactile simulation will allow residents to take full advantage of these low volume cases when encountered in the OR, and not be wasted with observation alone.   In the future, we plan to evaluate whether this simulation translates to real time “in vivo” skill, as well as to compare it to other modes of simulation.

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